A health economic evaluation of the Anaesthesia Choice for Creation of ArteriovEnouS Fistula (ACCess) study: Assessing the cost-effectiveness of arteriovenous fistulae creation under regional anaesthesia compared to local anaesthesia

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Abstract Background Establishing a reliable arteriovenous fistula (AVF) for haemodialysis (HD) is often complicated by early failure. Utilising regional anaesthesia (brachial plexus block, BPB) for AVF creation has previously been shown to improve short- and long-term AVF patency compared to local anaesthesia (LA). We report a comprehensive economic evaluation of the ACCess multicentre trial (comparing BPB vs LA) from the UK health system perspective. Methods Using ACCess trial data, we conducted a within-trial micro-costing analysis of 12-month resource use and outcomes [1], and a decision-analytic cost-effectiveness model over 5 years [2]. Costs of staff, drugs, equipment and consumables were derived and valued in 2024 prices. Utility values (EQ-5D and SF-6D) from trial respondents were used to estimate quality-adjusted life-years (QALYs) for the within-trial evaluation, supplemented by utility values linked to access modality from literature for the cost-effectiveness model. All costs and benefits were discounted at 3.5% per annum. The model combined a Markov process (to capture AVF functional states) and embedded decision trees (for AVF creation and revisions). Transition probabilities were based on ACCess trial primary outcome and patency rates and literature. We performed deterministic and probabilistic sensitivity analyses. Results In the 1-year within-trial analysis, BPB saved on average £1,139 per patient compared to LA (95% CI: –£1,255 to –£1,021; p < 0.001), driven mainly by fewer dialysis costs and infections. Excluding dialysis costs, the BPB procedure was modestly cost increasing at £116 (95% CI: £18 to £203) per patient. Differences in 1-year QALYs were small and not statistically significant. Over 5 years, the base-case model gave an incremental cost of £15,154 per patient (BPB more expensive) and a QALY gain of 0.347, yielding an incremental cost-effectiveness ratio (ICER) of £43,609 per QALY. Haemodialysis costs and differential tariffs for AVF and catheter (TCVC) were the main driver, as BPB improved survival and AVF use in the model as predicted by the patency and mortality rates observed from the trial. When ongoing dialysis costs were excluded, the ICER fell to just £1,182/QALY. Probabilistic analysis showed low probability BPB is cost-effective at £20 k–£30 k/QALY thresholds, rising to 84% at £50 k/QALY (the ICER credible interval was £31,064–£63,392). The model was most sensitive to dialysis cost parameters and transition probabilities. Conclusions BPB for AVF creation yields a net cost saving at 1 year versus LA. However, over five years its cost-effectiveness is marginal under standard UK thresholds, largely due to higher dialysis-related costs from prolonged survival and differential tariff for dialysis via AVF vs TCVC. Excluding dialysis delivery costs (or applying a higher willingness-to-pay) makes BPB highly cost-effective. These results highlight that while BPB may improve clinical outcomes, the long-term economic value of BPB depends on dialysis cost assumptions and reimbursement structure. This trial-based analysis provides crucial evidence for vascular access policy and the economic impact of anaesthesia choice for AVF creation.